Invertierte Papillome der Nase und ihrer Nebenhöhlen Langzeitergebnisse nach endoskopischer endonasaler Resektion

There is still some skepticism about endoscopic endonasal resection of inverted papillomas. We conducted a long-term retrospective study and examined 104 patients (82 male, 22 female) with inverted papilloma who were operated at the ENT-Department of the University of Erlangen between 1974 and 1997. The endoscopic approach was chosen in each case, either alone or in combination with external approaches. In 64.4% (67 cases), tumors of all T-classes were resected by endoscopic approach alone (T1:17.9%, T2:23.9%, T3:41.8%, T4:16.4%). For the rest of the patients an additional transoral and transfacial approach was necessary due to difficult tumor localization (T2:24.3%, T3:29.7%, T4:45.9%). The mean age of the patients was 55 years. The recurrence rate after primary endoscopic endonasal sinus surgery was 22.4% (15/67) and after combined endoscopic and external surgery 16.2% (6/37). Second salvage surgery after endoscopic sinus surgery was performed again endonasally in 46% (7/15) and externally in 53.3% (8/15). The recurrence rate after the endonasal approach was now 57.1% (4/7) and 50% (4/8) after external surgery. Third salvage surgery was performed again endoscopically in four cases and externally in four cases. The recurrence rate in both groups was 50% each, so that up to six operations, either endoscopically or externally, were necessary for complete tumor resection. The longest period for a tumor recurrence was 3.4 years after endoscopic sinus surgery and 9 years after combined endoscopic and external surgery. A tumor recurrence after endoscopic endonasal sinus surgery that could not be managed endoscopically again occurred in 12%. Tumor localization is the limiting factor for endoscopic endonasal sinus surgery of inverted papilloma. However, in 64.4% of cases, endoscopic endonasal sinus surgery alone was performed successfully without any loss of one patient. Long-term follow-up is necessary since the recurrence of tumor can happen after a long time. Endoscopic endonasal sinus surgery of inverted papilloma is safe and should be preferred due to its minimal invasive character.     

Sphenoidal and cavernous sinus resection for tumor

Malignant neoplasms as well as those with an aggressive locally invasive character involving the sphenoid sinus have been considered heretofore to be inoperable and incurable. Because of fear of entering the cavernous sinus, the proximity of the internal carotid artery laterally and the optic chiasm superiorly as well as the middle fossa contents, these patients were relegated to palliative regimens of irradiation and chemotherapy. As methods have been developed of managing hemorrhage from the cavernous sinus, exposure and control or bypass of the internal carotid artery and combined subcranial and intracranial resection, the frontiers of surgery in the sphenoid sinus have been advanced. We have resected eight patients with tumors involving the sphenoid sinus in whom the walls of the sinus were exenterated, portions of the cavernous sinus removed, the internal carotid artery skeletonized, anterior and middle fossa dura resected, and in a few the temporal lobe was excised. Follow-up ranges from six years to 10 months. There have been no perioperative deaths; one patient succumbed to general inanition with locally recurrent tumor at four months; the rest are all alive and well without evidence of tumor, with the exception of one patient. This patient has a local recurrence anteriorly from an inadequate margin due to a technical error, but there is no recurrence in the sphenoid sinus, the cavernous sinus or the middle cranial fossa.     

Nasopharyngectomy for recurrent nasopharyngeal carcinoma: a review of 53 patients and prognostic factors

CONCLUSIONS: Salvage surgery is a justified treatment for primary recurrence of nasopharyngeal carcinoma (NPC). Skull base surgery can play a role in rescuing patients with more advanced local recurrence of NPC. OBJECTIVES: The purpose of this study was to report the local control and overall survival outcome of patients with (NPC) with local failure who received salvage nasopharyngectomy and to identify prognostic factors. PATIENTS AND METHODS: Fifty-three consecutive patients who had primary recurrence of NPC and underwent salvage surgery with curative intention from July 1993 to December 2006 were retrospectively reviewed. The follow-up time ranged from 5.1 to 142.2 months. The numbers of cases of recurrent NPC stage were as follows: stage I, 26; stage II, 9; stage III, 10 and stage IV, 8. Fifty patients had one course of radiation therapy while 3 had two courses of radiation therapy before the salvage surgery. For the nasopharyngectomy, 2 patients underwent endoscopic approach and 33 underwent facial translocation, while 18 had craniofacial resection. Postoperative adjuvant treatment included radiation therapy, 4 cases; radiosurgery, 8 cases; concurrent chemoradiation therapy, 7 cases; and chemotherapy, 2 cases. RESULTS: The 5-year local control rates were T1, 58.3%; T2, 27.8%; T3, 53.3%; T4, 75.0%; and all stages, 53.6%. The 5-year overall survival rates were stage I, 64.8%; stage II, 38.1%; stage III, 25.9%; stage IV, 46.9%; and all stages, 48.7%. Multivariate analysis revealed that gender, margin status, adjuvant treatment type and parapharyngeal space involvement were significant impact factors of local control, whereas dura or brain involvement, local recurrence and adjuvant treatment type were significant impact factors of survival.     

Paranasal sinus mucoceles: surgical management and long term results

BACKGROUND: The aim of this study was to determine the best surgical approach in the treatment of paranasal sinus mucoceles according to their localization. MATERIAL AND METHODS: A retrospective analysis was carried out in 255 patients with 290 sinus mucoceles who were treated surgically at the ENT-Department of the Hospital Fulda gAG between 1983 and 2001. This series include 125 frontal sinus, 23 frontoethmoid, 41 ethmoid, 72 maxillary sinus and 26 sphenoid mucoceles. The patients' history, presenting symptoms, radiological findings, and surgical management were reviewed. Of them, 185 patients were followed by endoscopic and CT or MRI control during a period of up to 19 years, median follow-up was 12 years. RESULTS: In 168 out of 255 patients (66 %) the mucoceles were arisen due to previous sinus surgery, in 37 cases (14 %) after traumatic lesions, in 5 patients (2 %) due to chronic sinusitis and in 2 cases (<1 %) according to tumors. In 43 cases (17 %) no causes were found. In 78.8 % the previous operation was performed via an external approach, either according to Jansen/Ritter or Caldwell-Luc, contrary to 1.5 % after endonasal surgery. The median period until mucocele appearance was 15 years for maxillary sinus, 13 years for frontoethmoid, 10 years for ethmoid, and 8 years for frontal and sphenoid sinus celes, respectively. 201 mucoceles (69.3 %) have been operated endonasal micro-endoscopically, 18.6 % via the osteoplastic approach, 10 % endoscopically combined with an osteoplastic procedure and only 2 % according to Jansen/Ritter. Thereafter, recurrence of mucoceles was found in 4 patients only ( = 2.2 %; related to the endonasal approach = 1.6 %). CONCLUSION: Frontoethmoidal, ethmoidal, sphenoidal and maxillary sinus mucoceles are excellent indication for exclusively endonasal micro-endoscopic surgery. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located frontal or maxillary sinus mucoceles.     

Factors affecting recurrence of sinonasal inverted papilloma

The aim is to study clinical characteristics and recurrence rates for sinonasal inverted papilloma (NIP), to evaluate relevant factors for its recurrence, and to compare the curative rates of different surgical approaches. The Krouse classification for the 156 follow-up cases of the patients with NIP was as following: 26 cases in T1, 33 cases in T2, 94 cases in T3, and 3 cases in T4. A total number of 99 cases of endoscopic sinus surgery were included, of which 26 cases of lateral rhinotomy approach were combined with Caldwell Luc approach, and 31 cases of nasal endoscopy combined with traditional surgery, with average postoperative follow-up of 3–11 years. Of the 156 studied patients with NIP, male:female = 1.69:1, age varied from 18 to 77 years, with average of 56 years, 19 cases showed postoperative recurrence, of which 8 cases developed to be squamous cell carcinoma. Among these 8 cases, 3 patients showed no recurrence after treatment in 5 years, and the other 5 patients died in 3–2 years period. Tumor recurrence rates for different surgical approach are: 9.09 % for endoscopic surgical group, 23.08 % for traditional surgical group, and 12.12 % for combined surgical group; tumor malignancy rates for different surgical approach are: 2.02 % for endoscopic surgical group, 11.54 % traditional surgical group, and 9.09 % for combined group, and Chi-square test showed that the differences in recurrence and malignancy rates for NIP patients with different surgical treatments were not statistically significant (P > 0.05). Recurrence rates for different stages are: T1 at 3.85 %, T2 at 12.12 %, T3 at 14.89 %, and T4 at 0.00 %, and the differences in the recurrence rates for different stages were not statistically significant (P > 0.05) by Chi-square test. There are clear clinical features for NIP, and the recurrence is related to the thoroughness of the first time surgical removal of lesions and is less relevant with Krouse classification stage and surgical approaches.     

Factors influencing survival in ethmoid sinus cancer.

Nineteen patients with primary ethmoid sinus malignancies were treated at the Cleveland (Ohio) Clinic Foundation between 1976 and 1989. Pathologic diagnoses included adenocarcinoma (eight), sarcoma (four), squamous cell carcinoma (three), mucoepidermoid carcinoma (two), adenoid cystic carcinoma (one), and undifferentiated carcinoma (one). All patients underwent surgical resection: 13 had craniofacial resection, four had craniofacial resection/orbital exenteration, one had radical ethmoidectomy/maxillectomy/orbital exenteration, and one had transantral ethmoidectomy. Twelve patients had combined treatment with radiation therapy. Ten patients were alive with no evidence of disease. A trend toward improved prognosis is associated with negative surgical margins. Preservation of the globe was not associated with local recurrence at this site. A poor prognosis was noted with involvement of the dura, brain, nasopharynx, or sphenoid sinus.     

High-grade malignancies of the parotid gland: Effective use of planned combined surgery and irradiation

The trend toward treatment of parotid gland malignancies with planned combined surgery and postoperative radiation therapy is currently being followed by many centers, although prospective studies comfirming the efficacy of this treatment regimen have only recently begun. We have reviewed only our “high-grade” histologic types: adenocarcinomas, malignant mixed tumors, high-grade mucoepidermoid carcinomas, squamous cell carcinomas, and undifferentiated carcinomas. Acinic cell carcinomas, adenoid cystic carcinomas, and low-grade mucoepidermoid carcinomas were excluded from study because of their different biologic behavior. Since 1974, we have employed the approach of surgical extirpation with preservation of the facial nerve when possible for all parotid tumors, combined with planned postoperative radiation therapy (50-70 Gy). We reviewed the 37 cases of “high-grade” parotid gland malignancies and compared the patients treated with the combined modality approach with our historical patients treated initially with surgery alone. Despite an apparent higher stage at presentation, our combined treatment group ultimately had significantly better local control (70% vs. 20%), and an equivalent survival rate at five years. Tumor was present at the margin of resection in 14 (74%) cases treated with combined surgery and irradiation. The facial nerve was preserved in six of these patients with positive margins, and only one of these patients developed a local or regional treatment failure. In conclusion, our data confirms the efficacy of surgical exploration to determine the extent of disease and surgical resection, preserving facial nerve function if possible, followed by postoperative radiation therapy at adequate doses. Control of local-regional disease was much improved by combined modality therapy as opposed to surgical resection alone, despite the prevalence of residual microscopic disease in the resection margins. Facial nerve function is optimally preserved by this approach of conservative surgery combined with postoperative radiation therapy.     

Factors affecting the overall survival after salvage surgery in patients with recurrent nasopharyngeal carcinoma at the primary site: experience with 60 cases.

OBJECTIVE: To analyze the factors affecting overall survival after salvage surgery in patients with recurrent nasopharyngeal carcinoma at the primary site after a full course of radiotherapy. DESIGN: Retrospective analysis of 60 consecutive patients treated by surgical resection of the recurrent tumors, with a mean follow-up of 43.1 months (range, 19-96 months). SETTING: Academic tertiary referral center. RESULTS: The overall survival and locoregional relapse-free survival were 56% and 60% at 2 years, respectively, and 30% and 40% at 5 years. Twenty-nine (81%) of 36 patients died with uncontrolled local disease. The T stage of the recurrent tumors appeared to be an important prognostic factor. Age, sex, pathologic findings, and disease-free interval (time between previous radiotherapy and local recurrence) were not significant prognosis-affecting factors by the log-rank test. Multivariate analysis showed that patients with recurrent tumors of undifferentiated carcinoma, sarcoma, or small cell carcinoma had unfavorable prognoses. Uncontrolled local disease and the emergence of distant metastasis predicted grave results as well. Postoperative irradiation showed some benefit to patients, but the difference was not statistically significant. CONCLUSIONS: The T stage of the recurrence was the prominent prognosis-affecting factor in patients with recurrent nasopharyngeal carcinoma who received salvage surgery. Patients with local recurrence should be carefully selected for the salvage surgery. We recommend this surgery for patients with rT1, rT2, or limited rT3 lesions. The results of surgical resection in terms of local control and overall survival were slightly better than those of high-dose reirradiation, with fewer late complications.     

鼻内镜下蝶窦手术21例

目的 :探讨鼻内镜下治疗蝶窦良性病变的疗效和手术体会。方法 :2 1例患者在鼻内镜下进行鼻腔 蝶窦手术 ,其中全身麻醉 2例 ,局部麻醉辅以强化麻醉 19例。结果 :随访 3个月～ 4年。 2 0例痊愈 ,1例出现窦口闭锁 ,行再次手术开放 ,无一例出现严重并发症。结论 :局部麻醉鼻内镜下蝶窦手术具有视野清楚、损伤小、出血少、痛苦小等优点 ,是一种安全、有效的手术方式     

Surgical management of sinonasal inverted papillomas through endoscopic approach

We defined a standardized approach to surgery of sinonasal inverted papillomas (IP) for adequate and safe resection. A cohort of 65 patients treated from January 1995 to December 2005 at a single institution was retrospectively analyzed (mean follow-up: 28 months; range 1–132). The extension of the tumor was evaluated on clinical findings and computed tomography (CT) scan and/or resonance magnetic imaging (RMI). External and endoscopic surgical approaches were compared according to tumor extension, rate of local recurrence. Univariate analysis was used to review the impact on disease-free survival of factors related to the histopathological findings and the treatment. Endoscopic (alone or combined with transantral approach) and external surgery were used in 46 patients (71%) and 19 patients, respectively. Endoscopic approach (34/46) was performed to control IP in the nasal fossa, the ostiomeatal complex, the sphenoid sinus. It was combined with Caldwell-Luc procedure (12/46) for tumor extent into the lateral part of the maxillary sinus. The mean time for recurrences to occur was 19 months with range of 5–35 months. The rate of local recurrence was 17.6% (6/34) in endoscopic approach alone, 8.3% in endoscopic approach combined with a Caldwell-Luc procedure and 15.8% (3/19) in external approach. Tumor extension, excision with safe margins, associated malignancy or dysplasia have no significant impact on disease-free survival regardless of surgical procedure. On the basis of imaging evaluation and peroperative view of tumor extent, we propose a surgical strategy in which endoscopic approach could be used on the first attempt by trained surgeons. RMI is very useful to determine acute extent of the disease.     

Surgical outcomes of sinonasal inverted papilloma: a 17 year review

IntroductionInverted papillomas represent one of the most common benign neoplasic lesions located in the sinonasal tract. Owing to the local erosive behavior, tendency to recur and the potential for malignant transformation, surgical management of inverted papillomas is often challenging.ObjectiveThis study aimed to analyze the surgical outcomes of patients with inverted papillomas, according to the Krouse staging and the different surgical approaches.MethodsRetrospective study of patients diagnosed with sinonasal inverted papillomas who underwent surgical treatment between 2000 and 2016 at a tertiary referral hospital. Cases with follow-up less than 12 months were excluded. The rate and the time of recurrence were the main outcomes. Values of p < 0.05 were considered statistically significant.ResultsThirty-six cases with mean age of 60 years, predominantly male (72%), were included. The follow-up period ranged from 1 to 16 years, with an average of 4.5 years. Krouse T1 Stage corresponded to 11.1%; T2 occurred in 50% of cases; while T3 and T4 Stages accounted for 30.6% and 8.3% of patients, respectively. Most cases were approached by an endoscopic technique alone (83.3%), with a recurrence rate of 13.3%. Patients treated via a combined or open approach revealed a recurrence of 16.7%. No differences in the recurrence rate were reported when comparing endoscopic surgery with the open or combined techniques. Krouse Stage T3 had a significant association with inverted papillomas recurrence (p = 0.023). All inverted papilloma relapses occurred up to 2 years post-operatively. One case of malignant transformation was recorded (2.7%).ConclusionEndoscopic surgery did not increase the recurrence rates and can be a safe and efficient alternative to open or combined techniques. The recurrence of inverted papillomas seem to be related to the persistence of the disease and tend to occur early after primary surgery. Krouse T3 Stages may be associated with a higher recurrence of inverted papillomas.     

Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience

On the basis of an inception cohort of 270 patients with a previously untreated invasive squamous cell carcinoma of the true vocal cord (232 T N0M0, 35 T2N0M0, and 3 T3N0M0) and a minimum of 3 years of follow-up, the authors analyze the oncological and functional outcomes following frontolateral vertical partial laryngectomy without tracheotomy. The 5-year Kaplan-Meier actuarial survival estimate ranged from 83.1% for T1 tumors to 67.2% for T2 tumors (p = .005). On univariate analysis, a significant statistical relationship was noted between reduced survival and the following variables: increased age, increased Charlson comorbidity index score over grade 0, increased tobacco intake, increased alcohol intake, increased T stage, local failure, nodal failure, and development of a metachronous second primary cancer. The hospital mortality rate was 0.4%. A significant postoperative surgical complication was noted in 49 patients (18.1%). The predominant significant surgical complication was wound infection (19 patients; 7%), followed by seroma and major subcutaneous emphysema. No significant statistical relationship was noted in a comparison of each, significant postoperative complication (including postoperative death) with the variables under analysis. The incidence of secondary tracheotomy was 0.4%. The incidence of completion laryngectomy due to functional problems was 0%. The 5-year Kaplan-Meier actuarial local control estimate was 91% for T1 tumors and 68.7% for T2 tumors (p <.0001). Within the T1 tumors, the 5-year Kaplan-Meier actuarial local control estimate ranged from 96.2% for tumors without anterior commissure involvement to 74.7% for tumors with anterior commissure involvement (p = .0002). On univariate analysis, a significant statistical relationship was noted between an increase in local recurrence and the following variables: increased T stage, anterior commissure involvement, and pathological margin involvement. The overall disease control rate and laryngeal preservation rate were 92.9% and 93.3%, respectively.     

Proton beam radiation therapy for skull base adenoid cystic carcinoma

OBJECTIVE: To determine the treatment outcome and prognostic factors in patients with adenoid cystic carcinoma of the skull base treated with proton beam radiation therapy. DESIGN: Retrospective analysis. SETTING: Massachusetts General Hospital, Massachusetts Eye and Ear Infirmary, and Harvard Medical School, Boston. PATIENTS: From 1991 to 2002, 23 patients with newly diagnosed adenoid cystic carcinoma with skull base extension were treated with combined proton and photon radiotherapy. There was tumor involvement of the sphenoid sinus in 61% of patients (14), nasopharynx in 61% (14), clivus in 48% (11), and cavernous sinus in 74% (17). The extent of surgery was biopsy alone in 48% (11), partial resection in 39% (9), and gross total resection with positive margins in 13% (3). The median total dose to the primary site was 75.9 cobalt-gray equivalent. The median follow-up of all surviving patients was 64 months. MAIN OUTCOME MEASURES: Locoregional control and disease-free survival and overall survival rates. RESULTS: Tumors recurred locally in 2 patients at 33 and 68 months, respectively. No patients developed neck recurrence. Eight patients had distant metastasis as the first site of recurrence. The local control rate at 5 years was 93%. The rate of freedom from distant metastasis at 5 years was 62%. The disease-free and overall survival rates at 5 years were 56% and 77%, respectively. In multivariate analysis, significant adverse factors predictive for overall survival were change in vision at presentation (P = .02) and involvement of sphenoid sinus and clivus (P = .01). CONCLUSIONS: High-dose conformal proton beam radiation therapy results in a very encouraging local control rate in patients with adenoid cystic carcinoma of the skull base. Changes in vision at presentation and tumor involvement of the sphenoid sinus and clivus are important prognostic factors.     

Value of endonasal endoscopic surgery in the treatment of sphenoid cerebrospinal rhinorrheas. 15 cases

Surgical management of cerebrospinal fluid leaks (CSFL) has improved these few past years with the development of paranasal sinus surgery under optical guidance. CSFL localized in the sphenoid sinus represent only 5 to 15% of all CSFL. The authors have analyzed a serie of 15 patients having undergone surgery from 1992 to 1999 for CSFL: 10 cases followed pituitary gland surgery realized through sublabial-transsphenoidal approach, 2 cases followed head trauma, 1 case followed a secondary neurosurgical procedure following recurrence of a rathke's cleft cyst, 1 case followed medical treatment of a bulky pituitary gland adenoma and 1 case was associated to an empty sella syndrome. The surgical procedure has relied on sphenoid sinus approach through the sphenoethmoidal recess (SER) (n = 8), transethmoidal approach (TE) (n = 2) or transseptal approach (TS) (n = 7) followed by a filling of the defect by a graft of fat with biological glue (n = 17). Sometimes it was associated to a cartilagenous graft (n = 7) when there was a bone defect. The average period of hospitalisation was 5.2 days (4-21), mean follow-up was 2.9 years (6 months-7 years). RESULTS: The success rate was 80% (3 failures were observed), 2 patients underwent secondary procedures by TS approach with success. Our results combined with the literature data led us to propose an alternative surgical strategy adapted to each case. Endonasal surgery under optic guidance compared to the transrhinoseptal approach represents an attractive alternative with less undesirable iatrogenic consequences.     

晚期鼻腔鼻窦腺样囊性癌12例临床分析

目的总结原发于鼻腔鼻窦的晚期腺样囊性癌(ACC)的临床特征,探讨切缘病检结果以及复发或转移与预后的关系。方法回顾性分析12例晚期鼻腔鼻窦ACC患者的临床资料、治疗方法及预后。其中T3和T4期病变患者各6例,均无局部淋巴结及全身转移。首次治疗均以手术为主,9例联合术后放疗,4例联合化疗,复发及转移的治疗方式各异,仍以再手术为主。结果在20次首发及复发病灶的手术中,切缘阳性率高(75%,15/20),切缘阳性者生存时间最长达32年;随访期间局部复发7例(2例合并远处转移),单纯远处转移1例,局部复发并远处转移患者最长生存达32年。结论晚期鼻腔鼻窦ACC手术切缘阳性率高,局部复发率高,但局部复发或远处转移后仍能带瘤生存较长时间,在行根治性手术以及复发或转移治疗决策时应充分考虑患者的生存质量。     

Cancer of the buccal mucosa: Are margins and T-stage accurate predictors of local control?

Cancer of the buccal mucosa is an uncommon and aggressive neoplasm of the oral cavity. Less than 2% of patients treated for cancer of the oral cavity at Roswell Park Cancer Institute (RPCI) from 1971 to 1997 had primary buccal cancers. Because the majority of these patients did not undergo any adjuvant treatment, this group provided us with the opportunity to assess the relationship between margin status and local recurrence for both small (T1-T2) and large (T3-T4) tumors treated with surgery alone. MATERIALS AND METHODS: The RPCI tumor registry database reported 104 patients who were treated for buccal carcinoma. A retrospective chart review identified 27 patients who met our criteria for a buccal mucosal primary tumor (epicenter of the mass in the buccal mucosa). There were 13 men and 14 women, ranging in age from 34 to 94 years (mean, 75). Data were collected regarding patient demographics, presenting symptoms, stage, treatment received, and outcome. RESULTS: All patients underwent surgical resection of their primary lesion; 21 (75%) had T1 or T2 tumors. The rate of local recurrence was 56% for the group as a whole. Patients with close or positive margins had a 66% local failure rate as compared with 52% when surgical margins were negative (greater than or equal to 5 mm from the resection margin after tissue fixation; P = ns). Among those in whom negative margins were achieved, patients with T1-T2 disease had a 40% local failure rate with surgical resection alone. CONCLUSIONS: Local excision of T1 and T2 buccal mucosa cancers with pathologically negative margins had a high rate of local recurrence in our series. Low T-stage and negative margins are not adequate predictors of local control. Even early buccal tumors may benefit from adjuvant therapy to enhance local control.     

Craniofacial resection for malignant nasal and paranasal sinus tumors assisted with the endoscope

Background

Craniofacial resection is regarded as the treatment of choice for paranasal malignant tumors invading the skull base. Even with this approach, the surgical view remains obscured when tumors in the deep nasal and paranasal sinuses are resected. Endoscopy provides a wide and clear surgical view in the deep and narrow nasal cavity. We report two patients who underwent craniofacial resection assisted with endoscope.

Methods

Two patients with malignant paranasal sinus tumor invading the anterior skull base underwent endoscope-assisted craniofacial resection.

Results

To avoid a limited surgical view in the sinonasal cavity, we performed craniofacial resection with endoscopic osteotomy and several procedures in the nasal cavity. The neurosurgeon performed anterior skull base osteotomy at an appropriate site from above, while the otolaryngologist provided illumination with the endoscope from below and preserved the adjacent structures. The patients recovered uneventfully and the endoscopic examinations of both patients 18 months after the surgery showed no recurrence.

Conclusions

Endoscopes were useful for the craniofacial resection at osteotomy, providing illumination from below and at the several procedures in the deep part of the nasal cavity. If a lateral rhinotomy incision is made, the combined transfacial and transnasal approaches avoid the limited working angle associated with the transnasal approach alone. Although an endoscopic approach is useful for treating sinonasal tumors, we should recognize its advantages and limitations.     

Endonasal micro-endoscopic resection of sinonasal inverted papilloma

BACKGROUND: The goal of this study was to assess the potentials and limitations of endonasal micro-endoscopic surgery in the treatment of sinonasal inverted papilloma (IP) and to demonstrate long-term results. PATIENTS AND METHODS: From 1989 to 2005, 64 patients underwent resection of IP via an endonasal approach using either the endoscope or microscope. Charts were reviewed retrospectively for presenting symptoms, radiological and intraoperative data. All patients were followed by endoscopic and MRI control during a period of up to 174 months, median follow-up was 78 months. RESULTS: Our study group consisted of 26 male and 38 female patients with an average age of 54.3 years. The majority of the patients (67 %) complained of unilateral nasal obstruction. 52 patients (81 %) were referred for primary surgery. In 12 cases (19 %) recurrent tumors were operated. According to the Krouse classification for IP the tumors were staged as T1 = 11 (17 %) cases, T2 = 37 (58 %) and T3 = 14 (22 %). In two patients a squamous cell carcinoma was associated with an IP ( = T4 stage). Most tumors were localized within the nasal cavity (72 %) or the anterior ethmoid (62 %). In 10 patients an infiltration of the bony skull base was present. During the follow-up period 6 patients developed recurrencies corresponding to an overall recurrence rate of 9.4 %. CONCLUSIONS: The advances in endonasal micro-endoscopic surgery allow both safe and effective removal of IP with low morbidity, and therefore it should be the approach of the first choice. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located IP. Close follow-up is mandatory to ensure the surgical success.     

Evaluation and surgical management of isolated sphenoid sinus disease

OBJECTIVES: To evaluate the pathologic conditions, preoperative evaluation, treatment, and clinical outcomes associated with sphenoid sinus disease. DESIGN: Retrospective study. SETTING: Tertiary university-based referral center. PATIENTS: All patients with isolated sphenoid sinus disease managed surgically or in which surgery was considered a primary treatment option. MAIN OUTCOME MEASURES: Demographic data, presenting signs and symptoms, endoscopic and imaging findings, surgical management, surgical pathology, and clinical outcomes were investigated in patients presenting with sphenoid sinus disease to the Medical College of Wisconsin, Milwaukee, between January 1, 1991, and December 31, 2001. RESULTS: The study population included 17 women and 12 men with a mean age of 52.3 years (range, 15-82 years). The most common presenting symptom was headache (20 patients [69%]). Imaging evaluation included computed tomography and/or magnetic resonance imaging studies in all cases. Sphenoid sinus abnormality was variable and included sinusitis (11 patients [38%]), tumor (7 [24%]), mucocele (5 [17%]), fungal process (3 [10%]), and cerebrospinal fluid fistula (3 [10%]). Twenty-one cases (72%) were managed endoscopically and 4 (14%) were managed with a transseptal approach. One patient (3%) underwent combined extracranial-endoscopic transnasal approach, while another (3%) underwent a midface degloving approach. The remaining 2 patients (7%) did not undergo surgical intervention. CONCLUSIONS: Given the high prevalence of noninflammatory lesions within the sphenoid sinus, thorough preoperative evaluation is imperative. Initially, this should include nasal endoscopy and computed tomography to help define the location, extent, and character of the lesion. In some cases, magnetic resonance imaging may help further define the nature and extent of a lesion. Angiography should be considered if a vascular lesion is suspected. The clinical and imaging findings should all be taken into consideration when the surgical approach is planned.     

内窥镜蝶窦手术的麻醉改进和眼部并发症的预防

目的 :探讨鼻内窥镜手术治疗蝶窦病变的麻醉方法和预防眼部并发症的措施。方法 :在 6 5例蝶窦病变的手术治疗中均行局麻加经改进后的表麻 ;术中彻底止血 ,明确碟窦的位置、窦壁吸收与破坏情况 ,以及病变的部位、色泽和形状等特点 ,密切注意眼部症状 ,避免损伤视神经。结果 :随访 0 .5～ 2年。治愈 5 3例 ,复发 7例(其中内翻乳头状瘤 2例 ,慢性蝶窦炎并息肉 5例 ) ,5例失访 ,仅 5例发生眼部并发症。复发病例经再次手术而切除。结论 :在局麻加改进的表麻下能完成蝶窦内窥镜手术 ,熟悉解剖结构及熟练的手术技巧可减少眼部并发症的发生。